The results of open preperitoneal prosthetic mesh repair for acutely incarcerated or strangulated inguinal hernia: a retrospective study of 146 cases

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Mesh infection, although infrequent, is a devastating complication of mesh hernioplasties. The aim of this study was to systematically review and synthesize the available evidence on risk factors for synthetic mesh infection after hernioplasty. A systematic search was performed in PubMed and Scopus databases. The extracted data were synthesized with the methodology of meta-analysis. We identified six eligible studies that reported on 2,418 mesh hernioplasties. The crude mesh infection rate was 5%. Statistically significant risk factors were smoking (risk ratio [RR] = 1.36 [95% confidence interval (CI): 1.07, 1.73]; 1,171 hernioplasties), American Society of Anesthesiologists (ASA) score ≥3 (RR = 1.40 [1.15, 1.70]; 1,682 hernioplasties), and emergency operation (RR = 2.46 [1.56, 3.91]; 1,561 hernioplasties). Also, mesh infections were significantly correlated with patient age (weighted mean difference [WMD] = 2.63 [0.22, 5.04]; 2,364 hernioplasties), ASA score (WMD = 0.23 [0.08, 0.38]; 1,682 hernioplasties), and the duration of the hernioplasty (WMD = 44.92 [25.66, 64.18]; 833 hernioplasties). A trend toward higher mesh infection rates was observed in obese patients (RR = 1.41 [0.94, 2.11]; 2,243 hernioplasties) and in patients operated on by a resident (in contrast to a consultant; RR = 1.18 [0.99, 1.40]; 982 hernioplasties). Mesh infections usually resulted in mesh removal, and common pathogens included Staphylococcus spp., Enterococcus spp., and gram-negative bacteria. Patient age, ASA score, smoking, and the duration and emergency setting of the operation were found to be associated with the development of synthetic mesh infection. The heterogeneity of the available evidence should be taken under consideration. Prospective studies with a meticulous follow-up are warranted to further investigate mesh-related infections.

Laparoscopic transperitoneal hernioplasty (TAPP) repair of inguinal hernias is thought to be a difficult surgical technique with high complication rates. The present study evaluated TAPP based on prospective documentation. The primary aim of the study was analysis of the individual learning curve, comparing consultants with trainees. Secondary endpoints included postoperative morbidity, time of disability and rate of recurrence. A total of 8050 TAPP repairs have been performed since 1993. By 2001, 99.9 per cent of all hernia repairs were done by TAPP. The median operation time dropped from 50 min in the first 600 cases to 42 min thereafter. The morbidity rate decreased from 9.3 to 2.6 per cent, and the rate of recurrence from 4.8 to 0.4 per cent. Within the same interval the proportion of training procedures increased from 1.7 to 44.9 per cent in 2001. Morbidity and recurrence rates were similar for trainees and consultants. TAPP is an effective and safe technique. It can be performed in a standard way for all inguinal and femoral hernias. The present results indicate that TAPP is possible in a routine setting, as well as in the training situation for young surgeons.